Opioid abuse in Arizona

Arizona is among the top states for the amount of oxycodone and morphine its pharmacies, hospitals and doctors have purchased per capita since the DEA began publishing data in 2000. (Photo by Johanna Huckeba/Cronkite News)

Since 2010, more than 3,600 people have overdosed and died from opioids in Arizona. (Photo by Johanna Huckeba/Cronkite News)

PHOENIX – In an unrelenting quest for painkillers, Arizona pill seekers embark on almost daily missions to obtain fake or stolen prescriptions and shop their pain among doctors. Sometimes, pharmacists report, patients try to get “multiple, multiple narcotic” prescriptions from “multiple, multiple doctors.”

Though the Arizona State Board of Pharmacy and lawmakers have built ways to thwart prescription drug fraud, Arizona’s addicts and abusers are equally persistent. A Cronkite News review of almost 800 “fraud alerts,” which are regularly sent to the board by concerned medical professionals and pharmacists, details the extent to which doctors and pharmacists are confronted with people willing to try almost anything to get painkillers.

According to one alert, a woman received 130 narcotic prescriptions from 93 prescribers, dispensed by 41 pharmacies. Another patient “has had 50 visits over the past 12 months where a controlled substance prescription was filled. She has seen 22 different physicians/providers, and filled at 16 different pharmacies.”

A Mesa pharmacist also reported a female patient bringing in a prescription for Promethazine with codeine in October, but after calling the woman’s doctor, it was determined that the “prescription was written on either a stolen prescription pad or was created by the suspect.”

Another alert, submitted by a dentist, describes a woman, brown hair, 5 feet 4 inches tall, claiming she needed Percocet because of a codeine allergy. According to the dentist, “patient appeared inebriated, incoherent at times, details of events changed with each telling. Came with a gentleman using a walker, both insistent that she be given Percocet, angry that I wouldn’t provide it, left without paying.”

Cronkite News conducted a four-month investigation into the rise of prescription opioid abuse in Arizona. In 2015, more than 2 million grams of oxycodone alone came into the state, the third-highest total per capita in the country.

Dozens of journalists at Arizona State University examined thousands of records and traveled across the state to interview addicts, law enforcement, public officials and health care experts. The goal: uncover the root of the epidemic, explain the ramifications and provide solutions.

Since 2010, more than 3,600 people have overdosed and died from opioids in Arizona. In 2015, the dead numbered 701 – the highest of any year before, or nearly two per day, according to an analysis by the Arizona Department of Health Services.

The state launched the fraud alert system in 2013. Although the alerts often contains the name, address, physical description and sometimes the Social Security number of the potential drug seeker, no one – not the police, not the pharmacy board, not anyone – is responsible for further investigation.

“(Following up) is not part of our statutes, or our responsibility,” said the pharmacy board’s Executive Director Kam Gandhi. “We’re actually a conduit, we send off the information from what’s provided to us. We’re not the enforcer, (nor) generally follow up on it.”

Rob Dobrowski, the board’s information technologist, said the fraud alert system is just one way to provide “a public service to keep everyone informed on the ongoing fraudulent prescription activity.”

The board also runs the Controlled Substances Prescription Monitoring Program, or CSPMP, which is supposed to keep doctors and pharmacists accountable for the drugs they prescribe and keep addicts from getting them. When a patient comes into a pharmacy with a prescription, pharmacists log the drugs into the CSPMP. Doctors who use the system then can see what medications a patient already has received.

The CSPMP launched in 2009, but doctors were not legally required to look at a patient’s prescription history until the Legislature passed a mandate this year.

The physician groups took the position that (the mandate) “was not necessary, that it was overly burdensome, it would expose doctors to liability, it would take up their valuable time,” Arizona State Sen. John Kavanagh said.

After 20 years of police work in New York City during the crack epidemic, along with ambulance experience and friends lost to overdoses, Kavanagh understands the perils of addiction. He sponsored the mandate to protect pharmacists, doctors and addicts alike. By looking at a year of a patient’s prescription history, doctors can determine whether or not someone is in legitimate need of painkillers.

“One of the greatest harms is for a doctor to be inadvertently placed in the role of drug supplier,” Kavanagh said. “(The mandate) was an attempt to prevent patients from gaming the system by going to multiple doctors.”

The mandate was initially supposed to go into effect in January 2017, but has been pushed back to October 2017, eight years after the state established the program.

“It’s something the doctors really need to be working on,” said Teresa Stickler, owner and pharmacist at Melrose Pharmacy in Phoenix. “I know they’re not going to do anything until they’re forced to.”

According the Gandhi, the CSPMP is still in its “infancy stage” in Arizona. “Being mandated is the first step in assisting with the (opioid) problem nationwide. … The CSPMP prior to last year or even the year before that was very underutilized,” he said.

Although it contains Arizona’s up-to-date, real-time prescription drug data, CSPMP Director Elizabeth Dodge said her team’s main role with the database, “is just maintaining the data and storing it (for medical professionals). It’s not actually analyzing.”

Every month, however, the CSPMP does generate a report that flags patients who have seen four or more doctors and four or more pharmacies, at which point Dodge’s team will notify the patients’ physicians. Her office also assists law enforcement with open investigations involving prescription drug use.

Before coming to Arizona, Dodge was a pharmacist in a retail setting for 14 years in Nevada, where she used their prescription monitoring program.

One of Dodge’s main objectives is to make CSPMP profiles part of standard electronic health records among all health care providers. That way, a patient’s prescription history would appear with the medical history.

The Centers for Disease Control and Prevention data reflects a number of state successes for monitoring programs. New York and Tennessee passed mandates for their prescription drug monitoring programs, and saw a 75 percent and 36 percent decline in doctor shopping, respectively.

In Florida, regulating pain clinics in combination with a monitoring program, which they called E-FORCSE, resulted in a 50 percent decrease in overdose deaths caused by oxycodone, the CDC reports.

In addition to 163 million controlled substance prescription records, Florida law enforcement in 2015 “requested and received more than 6,509 investigative reports from E-FORCSE staff to assist in active criminal investigations,” according to Florida Surgeon General John Armstrong’s testimonial in the most recent annual report.

In the report, there’s optimism that with all states enacting monitoring programs, besides Missouri, they will “serve as an integral part of patient and public safety solutions addressing the national prescription drug epidemic.”

Even though she’d like to see its website streamlined, Stickler, the Phoenix pharmacist, appreciates the CSPMP and believes it has helped her practice.

“I think it’s great,” Stickler said. “It’s a great addition. I remember a pharmacy before the PMP came out, and you definitely had more abuse going on back then. Now that people can check on it, it’s harder to abuse.”

Arizona’s CSPMP and fraud alert system are two ways the board is attempting to stymie the opioid epidemic.

The fraud alerts are available to anyone who signs up to receive them through the pharmacy board.

Although there is no follow up, it allows medical professionals to identify suspected pill seekers through the personal information they provide.

Stickler said there should be more education and public awareness about the fraud alert system. Still, she said she is reluctant to use the system because the information is made public.

“We have had three fake prescriptions for promethazine with codeine in the past two months. I would like to get that information to other pharmacies, but I would not like it to get into the hands of somebody else,” Stickler explained. “People will know what we look for, and I don’t think that’s a good thing.”

Since it launched, more than 800 fraud alert submissions have been sent.

Though Dodge said the main role of the CSPMP is to store the information provided by pharmacists, she encourages doctors to use it even before the mandate goes into effect.

The legislation behind the CSPMP is intended to, “improve the state’s ability to identify controlled substance abusers or misusers and refer them for treatment, and to identify and stop diversion of prescription controlled substance drugs,” according to the CSPMP website.

“The PMP is just a tool in a whole big spectrum of things,” Dodge said. “But it is a really good tool, and my goal is to protect it and also at the same time make it really easy for people to use.”

Kavanagh said the pharmacy board has approached him about getting codeine cough syrups added in the CSPMP, even if they do not always require a prescription.fuetives to opioids for managing chronic pain.

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